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Pain : a very short introduction
In this 'Very Short Introduction', Rob Boddice explores the history, culture, and medical science of pain. Charting the shifting meanings of pain across time and place, he focusses on how the experience and treatment of pain have changed. He describes historical hierarchies of pain experience that related pain to social class and race, and the privileging of human states of pain over that of other animals. From the pain concepts of classical antiquity to expressions of pain in contemporary art, and modern medical approaches to the understanding, treatment, and management of pain, Boddice weaves a multifaceted account of this central human experience. Ranging from neuroscientific innovations in experimental medicine to the constructionist arguments of social scientists, pain is shown to resist a timeless definition. Pain is physical and emotional, of body and mind, and is always experienced subjectively and contextually.-- Source other than Library of Congress.
Book
Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care
Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP.
To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care.
This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020.
SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral).
Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records.
Overall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98; P < .001). Patient and clinical characteristics associated with transition to chronic LBP included obesity (aOR, 1.52; 95% CI, 1.28-1.80; P < .001); smoking (aOR, 1.56; 95% CI, 1.29-1.89; P < .001); severe and very severe baseline disability (aOR, 1.82; 95% CI, 1.48-2.24; P < .001 and aOR, 2.08; 95% CI, 1.60-2.68; P < .001, respectively) and diagnosed depression/anxiety (aOR, 1.66; 95% CI, 1.28-2.15; P < .001). After controlling for all other variables, patients exposed to 1, 2, or 3 nonconcordant processes of care within the first 21 days were 1.39 (95% CI, 1.21-2.32), 1.88 (95% CI, 1.53-2.32), and 2.16 (95% CI, 1.10-4.25) times more likely to develop chronic LBP compared with those with no exposure (P < .001).
In this cohort study, the transition rate to chronic LBP was substantial and increased correspondingly with SBT stratum and early exposure to guideline nonconcordant care.
Journal Article
Changes in Pain Sensitivity and Pain Modulation During Oral Opioid Treatment: The Impact of Negative Affect
Objective. Opioids are frequently prescribed for chronic low back pain (CLBP), but there are broad individual differences in the benefits and risks of opioid therapy, including the development opioid-induced hyperalgesia. This study examined quantitative sensory testing (QST) data among a group of CLBP patients undergoing sustained oral opioid treatment. We investigated whether individual differences in psychological characteristics were related to opioid-induced changes in pain perception and pain modulation.
Design. The six-month, open-label trial evaluated patients with low to high levels of negative affect (e.g., symptoms of distress, depression and anxiety); participants underwent QST at baseline (prior to initiating treatment) and during oral opioid treatment.
Setting. A chronic pain management center.
Patients. The 31 study participants had chronic discogenic back pain, with a pain intensity rating >3/10. Participants were divided into groups with high vs. low levels of Negative Affect (NA).
Results. In the previously-published manuscript describing the clinical outcomes of the trial, high NA patients achieved only about half of the analgesic effect observed in the low NA group (Wasan AD, Michna E, Edwards RR, et al. Psychiatric comorbidity is associated prospectively with diminished opioid analgesia and increased opioid misuse in patients with chronic low back pain. Anesthesiology 2015;123:861–72). The QST findings reported here suggested that tolerance to experimental (cold pressor) pain and conditioned pain modulation tended to decrease in the high NA group over the course of opioid treatment, while temporal summation of mechanical pain declined in the low NA group.
Conclusions. These results reveal that while the low NA group seemed to exhibit a generally adaptive, analgesic pattern of changes during opioid management, the high NA group showed a pattern more consistent with opioid-induced hyperalgesic processes. A greater susceptibility to hyperalgesia-promoting changes in pain modulation among patients with high levels of distress may contribute to a lower degree of benefit from opioid treatment in high NA patients.
Journal Article
You wouldn't want to live without pain
\"Describes what life would be like without pain.\"-- Provided by publisher.
Book
Targeted interventions to prevent transitioning from acute to chronic low back pain in high-risk patients: development and delivery of a pragmatic training course of psychologically informed physical therapy for the TARGET trial
Background
Low back pain (LBP) is a public health concern because it is highly prevalent and the leading cause of disability worldwide. Psychologically informed physical therapy (PIPT) is a secondary prevention approach that first aims to identify individuals at high risk for transitioning to chronicity and then provides tailored treatment to reduce that risk. Training models that are feasible to implement with acceptable training quality are needed to improve scalability for widespread implementation of PIPT. This manuscript describes the PIPT training program that was developed for training physical therapists providing PIPT in the TARGET trial.
Methods
The PIPT training program was developed, tested, and modified using an iterative process. Content development consisted of stakeholder engagement, beta testing, modification of training, and confirmation of final course objectives. Methods of delivery consisted of a website that included brief online educational modules followed by a live 8-h workshop that included video-based mock case scenarios and case-based role playing. Attitudes, beliefs, and confidence in implementing PIPT principles were assessed before and immediately after training to measure training quality and impact.
Results
Early stakeholder engagement and beta testing indicated the need for increased emphasis on experiential learning opportunities and patient-centered communication training. Booster training varied extensively across TARGET sites with involvement of ‘clinician champions’ providing brief follow-up sessions identified as best practice. Favorable post-training changes in physical therapist attitudes and beliefs toward biopsychosocial treatment orientation and increased confidence in implementing PIPT principles were observed.
Conclusions
PIPT training for provider participation in the TARGET trial was feasible to deliver. Course content was acceptable to physical therapists and resulted in improved beliefs and confidence in applying PIPT skills during clinical practice. Ongoing consultation and site-based continuing education were methods by which specific TARGET sites maintained or augmented PIPT skill training; however, implementing ongoing training was challenging in general. Due to the pragmatic nature of the TARGET trial, it was not possible to directly measure the effect of PIPT training on treatment fidelity, which was a limitation of our approach.
Trial registration
ClinicalTrials.gov,
NCT02647658
. Registered on 6 January 2016.
Journal Article
The efficiency of tactile discrimination training and oculomotor exercises in people with chronic neck pain: a randomized controlled trial
Background
Tactile discrimination training (TDT) and oculomotor exercises (OEs) have been widely used somatosensory-based interventions for a wide range of chronic pain conditions. There is, however, little evidence for the effectiveness of these approaches in people with chronic neck pain. This study aimed to determine the superiority of one intervention over another on pain outcomes in people with chronic neck pain.
Methods
Fifty seven participants were randomly divided into three groups: TDT, OEs, and a control group who received no intervention. TDT, OEs groups received either TDT or OEs, respectively, three times per week for four weeks. The control group received no intervention. Pain intensity, neck pain-related disability, pressure pain thresholds (PPTs), mechanical pain of temporal summation (mTSP), and conditioned pain modulation were assessed as pain outcomes. Depending on the normality, a repeated measures ANOVA or F1-LD-F1 design was used to analyse the data.
Results
A significant group*time interaction and main effects for time were found for pain intensity (p: 0.001, p: 0.001, respectively) and pain-related disability (
p
< 0.019,
p
< 0.009; respectively). There was a significant main effect for time for mTSP at the painful side of the neck (p: 0.022). TDT and OEs resulted in a significantly higher improvement in pain intensity (
p
: 0.005,
p
< 0.001; respectively) and neck pain-related disability (
p
: 0.005,
p
: 0.007; respectively). There was a higher improvement in pain intensity in OEs group compared to TDT group (p: 0.010). A significantly higher improvement in PPT at the painful site after OEs was found (p: 0.038). The control group demonstrated a significantly higher improvement in mTSP in the painful area of the neck (p: 0.048). There were no other significant within- or between-group changes.
Conclusion
OEs and TDT are effective somatosensory-based interventions for improving pain intensity and pain-related disability.
Impact
This study demonstrated that sensory retraining interventions improves the subjective pain perception.
Trial Registration
Trial Registration Number: NCT05605132, Date of trial registration: 10/29/2022, Name of trial registry: Neck Pain.
Journal Article
When your child hurts : effective strategies to increase comfort, reduce stress, and break the cycle of chronic pain
\"Parents of a child in pain want nothing more than to offer immediate comfort. But a child with chronic or recurring pain requires much more. His or her parents need skills and strategies not only for increasing comfort but also for helping their child deal with an array of pain-related challenges, such as school disruption, sleep disturbance, and difficulties with peers. This essential guide, written by an expert in pediatric pain management, is the practical, accessible, and comprehensive resource that families and caregivers have been awaiting. It offers in-the-moment strategies for managing a child's pain along with expert advice for fostering long-term comfort\"--Page 4 of cover.
Book
The Effects of Ultrasound-Guided Transversus Abdominis Plane Block on Acute and Chronic Postsurgical Pain After Robotic Partial Nephrectomy: A Prospective Randomized Clinical Trial
Abstract
Background
Use of a locoregional analgesia technique, such as the ultrasound-guided transversus abdominis plane block (TAPb), can improve postoperative pain management. We investigated the role of TAPb in robotic partial nephrectomy, a surgery burdened by severe postoperative pain.
Methods
In this prospective trial, patients with American Society of Anesthesiologists class I–III physical status undergoing robotic partial nephrectomy were randomly assigned to standard general anesthetic plus ultrasound-guided TAPb (TAP group) or sole standard general anesthetic (NO-TAP group). The primary end point was morphine consumption 24 hours after surgery. Secondary outcomes were postoperative nausea and vomiting in the first 24 hours, sensitivity, and acute and chronic pain, as measured by multiple indicators.
Results
A total of 96 patients were evaluated: 48 patients in the TAP group and 48 in the NO-TAP group. Median morphine consumption after 24 hours was higher in the NO-TAP group compared with the TAP group (14.1 ± 4.5 mg vs 10.6 ± 4.6, P < 0.008). The intensity of acute somatic pain and the presence of chronic pain at three and six months were higher in the NO-TAP group.
Conclusions
Our results show that TAPb can significantly reduce morphine consumption and somatic pain, but not visceral pain. TAPb reduced the incidence of chronic pain.
Journal Article